Abstracts:

GUEST SPEAKER
How to increase kidney transplantation? ABO-incompatible and/or HLA-incompatible transplants are one of the solutions
L. Rostaing11Nephrology and Organ-Transplant Department. University Hospital, Toulouse, France

Due to the scarcity of deceased donors and the increasing number of kidney-transplant candidates, every large kidney-transplant centre has developed living kidney transplantation but, in this setting, we are often faced with ABO-incompatibility (ABOi) and/or HLA-incompatibility (HLAi).
ABO kidney transplantation (KT) was developed and has been widely used in Japan since the 1990s; this procedure has now used worldwide. The most recent data show that the long-term results of ABOi KT, in terms of patient- and allograft-survival rates, are as good as those observed in ABO kidney transplantation. This is mainly because ABOi patients undergo desensitization before transplantation, which is based on i) apheresis techniques to remove isoagglutinins, and ii) rituximab therapy associated with standard immunosuppression to prevent re-synthesis of these isoagglutinins.
Once kidney transplantation is performed in ABOi patients, in most cases, accommodation takes place after a few weeks, i.e. the allograft is not rejected whereas the potential detrimental isoagglutinins are still present. However, due to the desensitization procedures ABOi KT patients can present within the first days or weeks post-transplant with a greater occurrence of surgical- and infection-related complications compared to ABO-compatible recipients.
The situation is more complex in the setting of HLA incompatibility. HLAi is defined by the presence of one or more anti-HLA alloantibodies before kidney transplantation that are directed against the recipient, i.e. donor-specific alloantibodies (DSA). DSAs are detected by the Luminex technique and, when present, their intensity is assessed by mean fluorescence intensity (MFI). The threshold for positivity varies from one laboratory to another but is generally considered to be positive when MFI is >1000.
When attempting kidney transplantation in the setting of DSAs one faces the risk of both acute and chronic antibody-mediated rejection (AMR). AMR is prevented by powerful posttransplant immunosuppression (induction therapy, plus tacrolimus, mycophenolate mofetil, and steroids) and, in the setting of living-donor by pretransplant desensitization than can rely either on intravenous immunoglobulins (IVIg) plus rituximab or on apheresis plus rituximab. Apheresis can be either plasmapheresis or immunoadsorption. In most patients, these strategies are associated with a decrease in DSA(s), which makes the initial positive crossmatch become negative. However, due to a rebound of DSAs at the time of transplantation, immediate posttransplant apheresis might be continued for a few days/weeks to avoid AMR. Because haemodialysis is very expensive and is associated, to some extent, with a high rate of mortality, it has been shown that HLAi kidney transplantation is more cost-effective than haemodialysis and is associated with improved quality of life.
In my presentation I will review the published literature on this subject and present the data from our centre, which has the most extensive experience in this setting in France.

Background: At this time, when dialysis patients still die because of the lack of kidney transplants, the priority of transplant teams and national agencies is to compensate for this by transplanting organs from living donors.Objectives: Following enlargement of French bioethics law in 2011, the Department of Nephrology and Organ Transplantation at the University Hospital of Toulouse (France) has implemented different methods to avoid these incompatibilities. This has resulted in a dramatic increase in the total number of kidney transplants carried out. These incompatible kidney transplants are associated initially with increased costs (mainly related to desensitization procedures) but, after 2 to 3 years, the cost savings when compared to hemodialysis are considerable. In addition, these incompatible kidney-transplant patients have benefited from greatly improved quality of life.Methods: The use of a desensitization protocol is implemented at pretransplant, and at posttransplant if necessary; it relies on removing the culprit antibodies (isoagglutinins and donor-specific alloantibodies [DSAs]) by apheresis, and preventing their re-synthesis using immunosuppressants. Apheresis comprises plasmapheresis, immunoadsorption, and double-filtration plasmapheresis. We have coupled these processes with a hemodialysis session to save time. The number of pretransplant sessions required is guided by the serum concentrations of isoagglutinins and/or DSA(s).Each patient and each pretransplant therapeutic sequence is different: it is adapted according to his/her type of incompatibility.Results: Since March 2011, 49 ABO- and/or HLA-incompatible patients have received a transplant using this desensitization protocol. So far, 43 cases have had successful outcomes at posttransplant.Conclusion/Application to practice: This desensitization series is by far the largest reported in France.

Background: Infection is a common cause of morbidity and mortality in renal transplant recipients (TPs).
Objectives:To analyse hospitalisations for TPs with infectious cause in the Nephrology Unit and the incidence of pyelonephritis and germs involved and complications.Methods: We analysed all infections in TPs at the Nephrology Unit during 2013.Results: There was 176 hospitalisations in TPs, of which 64 were for infectious causes (36.4% hospitalisations). The most common infection was pyelonephritis (43 hospitalisations 68.3% of hospitalisations caused by infection). There was 5 patients who required ICU admission for Septic Shock >28 days stay. No deaths was recorded in patients with pyelonephritis graft. 4 patients were readmitted for pyelonephritis graft. 100% of pyelonephritis in which microorganism was isolated from the culture was produced by gram negative organisms (E coli, Klebsiella, Pseudomonas, Enterococcus).Conclusion/Application to practice: Renal allograft pyelonephritis was the most common cause of hospitalisation by infectious disease. The infectious aetiology most frequently isolated was gram negative.

Background: The first successful pregnancy after kidney transplantation was reported in 1963 by Dr Joseph Murray. Until 2004, 1097 pregnancies in 716 kidney recipient women were registered at the National Transplantation Pregnancy Registry in North America.
For women with end-stage kidney disease (ESKD) of child-bearing age with a functioning kidney, renal transplantation offers a chance to start a family.Objectives: Pregnancies in renal transplant recipients involve risks for graft and fetus. The pregnancy rate is 5%, 35% of them do not progress beyond the 1st trimester. Pre-pregnancy graft function has a significant influence on both neonatal outcome and maternal graft survival.
Our experience shows, that when planning pregnancy in kidney transplant recipient, important aspects should be taken into consideration such as the influence of pregnancy on renal grafts and maternal morbidity.Methods: E.H. is a 37 year old Bedouin woman, transplanted in 1996 from a living donor in India. Prior to the transplant she conceived once but had a miscarriage.Two years after transplantation she delivered a healthy baby boy. Between 1996 and 2011 she gave birth to 6 children. All 6 pregnancies were spontaneously conceived.The kidney function was stable before, during and after the pregnancies.Results: Our experience shows, that when planning pregnancy in kidney transplant recipient, important aspects should be taken into consideration such as the influence of pregnancy on renal grafts and maternal morbidity, the influence of renal graft on pregnancy, and the affect of immunosuppressive agents on pregnancy. All those contributed for bringing joy and happiness to this family.

Background: Kidney transplantations are successfully performed in all Western countries, but the number of patients waiting for organs from deceased donors far exceeds the number of organs available. This shortfall has promoted donation by living donors, who enter the donation process with feelings of hope, concern and patience in order to be accepted or rejected for donation.Objectives: To investigate the perceived experiences and considerations among potential kidney donors in relation to acceptance or rejection as donors.Methods: A phenomenological-hermeneutic approach was applied in the study. Semi-structured interviews were conducted with 16 participants after evaluation. The Ricoeur’s theory of data interpretation was analysed on three levels: naïve reading, structural analysis, critical interpretation and discussion.Results: Accepted donors experienced relief and delight. Reflections were made on being prepared for donation and on the risks involved. Relationships between donors and recipients became closer. Rejected donors experienced frustration and disappointment, including anxiety about the recipient’s prospects. Rejected donors reflected on the reason for rejection, including considerations about life style changes. Reactions from relatives had an impact on donors.Conclusion/Application to practice: Both the accepted and rejected donors were vulnerable and in need of attention, engagement, support and care. Nurses should be aware that dialogue with donors, including reflections on personal experiences, is important in order to reduce and alleviate vulnerability and to give the best possible support and attention, including the opportunity to promote optimal post-donation outcomes.